Prophylactic Proton Pump Inhibitors in Upper Gastrointestinal Bleeding: Impact and Underprescription in a French Multicentric Cohort.

BACKGROUND: Appropriate prescription of Proton pump inhibitors (PPIs) remains an important concern amid the rising overuse. A gap exists in the literature regarding the benefit of PPI prophylaxis and the consequences of underprescription in patients at risk for upper gastrointestinal bleeding (UGIB). AIMS: This study aims to describe the characteristics of hemorrhage in relation to PPI use in patients experiencing UGIB, with a focus on high-risk individuals requiring gastroprotection. METHODS: Data from a French multicentric cohort of patients experiencing UGIB were analyzed. Patients using PPI were compared to those without PPI considering bleeding etiologies and outcomes of peptic ulcer disease (PUD)-related hemorrhage. The rate of PPI use and its effect on bleeding characteristics in high-risk populations, defined based on international guidelines, were also assessed. RESULTS: Among 2497 included patients, 31.1% were on PPI at bleeding onset. PPI users exhibited a significantly lower rate of PUD-related bleeding in comparison with those without PPI (24.7 vs 40.8%, respectively, p < 0.0001). Similar difference was observed in high-risk populations, of whom, only 40.3% had gastroprotection with PPI before bleeding onset. PPI prophylaxis, however, did not influence the severity of bleeding in the general study population or in high-risk groups. Multivariate analysis identified age, comorbidities, and having more than two anti-thrombotic agents as predictors of severe bleeding. CONCLUSIONS: PPI users appear to have a lower rate of bleeding ulcers compared to non-users. However, underprescription in high-risk groups raises the need for standardized care to ensure appropriate PPI use.

Cirrhotic patients with portal hypertension-related bleeding and an indication for early-TIPS: a large multicentre audit with real-life results.

BACKGROUND: The Baveno VI consensus meeting concluded that an early TIPS must be considered in high-risk cirrhotic patients presenting with variceal bleeding (VB) (Child B + active bleeding at endoscopy or Child C10-13 patients). Whether this therapeutic approach is feasible in a real-life setting remains unclear. AIMS: To determine (1) the proportion of patients eligible for early-TIPS among cirrhotic patients with VB, (2) the proportion of these patients who underwent early-TIPS placement and the main reasons for discarding TIPS, and (3) the outcomes of patients who experienced early-TIPS placement in a large, national, prospective, multicentre audit including academic and non-academic centres. MATERIALS AND METHODS: All French centres recruiting gastrointestinal bleeding were invited to participate. All consecutive patients with cirrhosis and PHT-related bleeding were included. RESULTS: 964 patients were included (58 centres: 26 academic, 32 non-academic; patient characteristics: male sex, 77%; age, 59.6 ± 12.1 years; aetiologies of cirrhosis (alcoholic,viral/other, 67%/15%/18%); source of bleeding (EV/GV/other, 80/11/9%); active bleeding at endoscopy 34%; Child A 21%/B 44%/C 35%. Overall, 35% of the patients were eligible for early-TIPS, but only 6.8%, displaying less severe cirrhosis underwent early-TIPS placement. The main reason for discarding TIPS was a lack of availability. The actuarial probability of survival at one year was significantly increased in early-TIPS patients (85.7±0.07% vs 58.9±0.03%, p=0.04). The severity of liver disease was the only parameter independently associated with improved one-year survival. CONCLUSION: In this real-life study, one-third of the cirrhotic patients admitted for VB fulfilled the criteria for early-TIPS placement, whereas only 7% had access to TIPS. TIPS was restricted to patients displaying less severe cirrhosis. The severity of liver disease was the only parameter that influenced survival.

Microscopic colitis or functional bowel disease with diarrhea: a French prospective multicenter study.

OBJECTIVES: To describe the characteristics of a cohort of patients with microscopic colitis (MC; lymphocytic (LC) or collagenous (CC) colitis) and to compare them with patients with functional bowel disorder with diarrhea (FBD-D). METHODS: Between September 2010 and June 2012, patients fulfilling the following inclusion criteria were prospectively included in 26 centers in France: (i) having at least three bowel movements daily with change in stool consistency; (ii) duration of abnormal bowel habit >4 weeks; and (iii) normal or near-normal colonoscopy. Each patient underwent a colonoscopy and colonic biopsies. We compared the demographic, clinical, biological, and etiological characteristic of patients with MC (CC and LC) with those of control patients with FBD-D. RESULTS: A total of 433 patients were included: 129 with MC (87 LC and 42 CC), 23 with another organic disease, and 278 with FDB-D, including patients with diarrhea and abdominal pain who met the criteria of Rome III (irritable bowel syndrome with diarrhea) and patients with functional diarrhea without abdominal pain. Logistic regression analysis identified the following independent predictors of MC: age >50 years (odds ratio (OR)=3.1, 95% confidence interval (CI)=1.6-5.9), presence of nocturnal stools (OR=2, 95% CI=1.1-3.9), weight loss (OR=2.5, 95% CI=1.3-4.7), duration of diarrhea <12 months (OR=2.0, 95% CI=1.1-3.5), recent introduction of new drugs (OR=3.7, 95% CI=2.1-6.6; P<0.0001), and the presence of a known autoimmune disorder (OR=5.5, 95% CI=2.5-12). CONCLUSIONS: Age >50 years, the presence of nocturnal stools, weight loss, the introduction of a new drug, and the presence of a known autoimmune disease increase the probability of MC and thus the indication for colonoscopy with biopsies.

Roux-En-Y Fistulo-Jejunostomy as a salvage procedure in patients with post-sleeve gastrectomy fistula.

BACKGROUND: Sleeve gastrectomy (SG) is currently the most common bariatric procedure in France. It achieves both adequate excess weight loss and significant reduction of comorbidities. However, leak is still the most common complication after SG. Nevertheless, its risk of occurrence is <3% in specialized centers. Its management is difficult, long, and challenging. Although the procedure is commonly endoscopic and nonoperative, the management of post-SG fistulas could sometimes be surgical, including peritoneal lavage, abscess drainage, disrupted staple line suturing, resleeve, gastric bypass, or total gastrectomy. Roux-en-Y fistulojejunostomy (RYFJ) has been described as a salvage option. In this study, we report the early results of RYFJ for post-SG fistula, emphasizing indications, operative technique, and short-term outcome. METHODS: Between January 2007 and December 2012, we treated 62 patients with post-SG fistula. Before surgery, intra-abdominal or thoracic abscesses or collections were either excluded or treated by computed tomographic scan-guided drainage or even surgery. Endoscopic stenting was then attempted. After optimization of the nutritional status in case of failure of endoscopic measures, some of the patients underwent RYFJ. RESULTS: Between January 2007 and December 2012, a total of 21 patients (16 women and 5 men) had RYFJ for post-SG fistula. Mean age was 47 years (range, 22-59 years). Procedures were performed laparoscopically in all but 3 cases. The rate of secondary conversion to laparotomy was 11.1%. The was no mortality. The postoperative morbidity rate was less than 5%. The rate of fistula control was eventually 100%. CONCLUSIONS: RYFJ is a safe and feasible salvage procedure for the treatment of patients with post-SG fistula. Longer outcome analysis is, however, needed especially regarding the physiological and metabolic behavior of the procedure.

Prognostic factors associated with upper gastrointestinal bleeding based on the French multicenter SANGHRIA trial.

Background and study aims Prognostic and risk factors for upper gastrointestinal bleeding (UGIB) might have changed overtime because of the increased use of direct oral anticoagulants and improved gastroenterological care. This study was undertaken to assess the outcomes of UGIB in light of these new determinants by establishing a new national, multicenter cohort 10 years after the first. Methods Consecutive outpatients and inpatients with UGIB symptoms consulting at 46 French general hospitals were prospectively included between November 2017 and October 2018. They were followed for at least for 6 weeks to assess 6-week rebleeding and mortality rates and factors associated with each event. Results Among the 2498 enrolled patients (mean age 68.5 [16.3] years, 67.1 % men), 74.5 % were outpatients and 21 % had cirrhosis. Median Charlson score was 2 (IQR 1-4) and Rockall score was 5 (IQR 3-6). Within 24 hours, 83.4 % of the patients underwent endoscopy. The main causes of bleeding were peptic ulcers (44.9 %) and portal hypertension (18.9 %). The early in-hospital rebleeding rate was 10.5 %. The 6-week mortality rate was 12.5 %. Predictors significantly associated with 6-week mortality were initial transfusion (OR 1.54; 95 %CI 1.04-2.28), Charlson score > 4 (OR 1.80; 95 %CI 1.31-2.48), Rockall score > 5 (OR 1.98; 95 %CI 1.39-2.80), being an inpatient (OR 2.45; 95 %CI 1.76-3.41) and rebleeding (OR 2.6; 95 %CI 1.85-3.64). Anticoagulant therapy was not associated with dreaded outcomes. Conclusions The 6-week mortality rate remained high after UGIB, especially for inpatients. Predictors of mortality underlined the weight of comorbidities on outcomes.

Roux-en-Y Gastro-jejunostomy for Complex Leak After the "Nissen" Variant of Sleeve Gastrectomy.

BACKGROUND: Recently, improvised variants of sleeve gastrectomy SG were reported as alternative bariatric options in patients suffering from both morbid obesity and GERD, including mainly additional anterior or posterior fundoplication over a partially sleeved stomach. METHODS: We present the case of a 29-year-old male patient with a body mass index (BMI) of 46.2 kg/m2 underwent laparoscopic SG with concomitant posterior fundoplication: Nissen-SG (N-SG). At postoperative day (POD) 4, he presented with epigastric pain, nausea, and 40 °C fever. The abdomen was tender with signs of peritonitis. Explorative laparotomy displayed a massive gastric leak with generalized peritonitis. Peritoneal lavage was performed. the patient was transferred to our department for the management of persistent SGL. RESULTS: Initial management comprised total parenteral nutrition and wide-spectrum intravenous antibiotics. Three weeks later, the patient underwent laparoscopic exploration. As shown in the video, at least two leaks were individualized, including one, anterior, catheterized by the pigtails, and the other one, posterior, impossible to reach endoscopically (Fig. 1). A residual abscess, located between the left crus, the pancreas, and the upper edge of the spleen, was evacuated. Eventually, Roux-en-Y gastro-jejunostomy was performed CONCLUSION: The adjunction of a posterior fundoplication may have contributed to the multiple and complex occurrence of SGL. Having an ill-vascularized redundant fundus may have increased ischemia of the GE junction. Moreover, it is more difficult to perform endoscopic treatment in a plicated and sleeved stomach as well.

Preoperative rectosigmoid endoscopic ultrasonography predicts the need for bowel resection in endometriosis.

BACKGROUND: Rectosigmoid endometriosis is an underdiagnosed disease responsible for abdominal pain, transit disorders and rectal bleeding. Two surgical approaches, rectosigmoid bowel resection (segmental or patch) or intramuscular layer dissection (shaving), are available. AIM: To assess whether the lesion features observed via preoperative rectosigmoid endoscopic ultrasonography (RS-EUS) might predict the need for bowel resection. METHODS: This multicentric retrospective study was conducted on patients with rectosigmoid endometriosis who underwent a curative surgical procedure, evaluated by RS-EUS performed by two trained operators, between January 2012 and March 2018. A univariate statistical analysis was performed on nodules' RS-EUS features (thickness, width, infiltration of the submucosae, presence of a bump into the digestive lumen and presence of multiple rectosigmoid localizations). A multivariate logistic regression was then performed on the significant results. RESULTS: Of the 367 patients, 73 patients with rectosigmoid endometriosis were evaluated by RS-EUS and underwent rectosigmoid surgery. After the univariate analysis was completed, thickness, width and infiltration of the submucosae were identified as potential predictive factors for bowel resection. In a multivariate logistic regression model, only thickness appeared to be a significant [odds ratio (OR) = 1.49, 95% confidence interval (CI): 1.04-2.12, P = 0.028] predictive factor for bowel resection. Receiver operating characteristic analysis performed showed that a thickness over 5.20 mm might be used as cut-off with a sensitivity of 76%, a specificity of 81%, and an area under carve = 0.82. The cut-off values for 100% sensitivity and 100% specificity were 0.90 mm and 10.00 mm, respectively. A trend concerning width to predict the need for resection was also observed (OR 1.12, 95%CI: 1.00-1.26, P = 0.054). CONCLUSION: The presence of a rectosigmoid nodule of endometriosis greater than 5.20 mm thick on RS-EUS might predict the need for bowel resection.

Correction to: Massive Gastrointestinal Bleeding Due to Splenic Artery Erosion by a PigTail Drain in a Post Sleeve Gastrectomy Leak: a Case Report.

The name of author Frédérick Moryoussef was incorrect in the original article - it is correct here.

Evaluation of endoscopic retrograde cholangiopancreatography procedures performed in general hospitals in France.

OBJECTIVE: Evaluate endoscopic retrograde cholangiopancreatography (ERCP) in general hospitals in France. METHODS: Prospective study of ERCP procedures performed in 28 centers during an 18-month period. Success was assessed at day 1; morbidity and mortality were assessed at 30 days. RESULTS: 2708 ERCP procedures were performed in 28 centers. The rate of success was 92.1% and was higher among centers performing more than 200 procedures annually (OR 2.07 [1.522.86]). Therapeutic success was correlated with diameter of the common bile duct>6 mm (OR 9.1 [7.15-11.57]) and center activity level (OR 1.91 [1.38-2.6]). The rate of complications and deaths were 9.1% and 4%; procedure-specific mortality was 0.8%. Morbidity was lower in centers performing more than 200 procedures annually (OR 0.36 [0.22-0.6]) and when the operator considered the procedure easy to perform (OR 0.5 [0.35-0.74]). Mortality was correlated with ASA score (OR for patients with ASA scores 2, 3, 4 were 9 [1-66], 53.3 [7.3-392] and 164.7 [21.71249]) respectively, occurrence of a complication (OR=3.9 [1.96-7.78]), diameter of the common bile duct, and technical success (OR=0.49 [0.27-0.88]). CONCLUSION: This study shows that success of ERCP and post-ERCP morbidity are related to center activity level while post-ERCP mortality is strongly linked with the patient's ASA score.

Cystic dystrophy of the duodenal wall associated with chronic alcoholic pancreatitis. Clinical features, diagnostic procedures and therapeutic management in a retrospective multicenter series of 23 patients.

AIM OF THE STUDY: The aim of this retrospective multicenter study was to collect data from patients with chronic alcoholic pancreatitis and cystic dystrophy of the duodenal wall in order to better understand the outcome after medical, endoscopic and/or surgical treatment. PATIENTS AND METHODS: The data from medical records of 23 patients consecutively seen in ten primary referral centers from January 1990 to July 2004 were studied. Clinical, biological, and endoscopic features as well as imaging findings were recorded. Response to treatment was noted. RESULTS: Twenty-three patients (20 men), aged 45 years (range: 30-66), with chronic alcohol intake, cystic dystrophy of the duodenal wall, and previously known (N=14) or simultaneously diagnosed (N=9) chronic pancreatitis were included. Symptoms most frequently encountered were abdominal pain (N=22) and weight loss (N=16). An abdominal ultrasound was available for 10 patients, abdominal computed tomography for 22, upper endoscopy for 18, and endoscopic ultrasonography for 22. Endoscopic ultrasonography enabled diagnosis of cystic dystrophy of the duodenal wall in 19/22 patients. Six patients were symptom-free after alcohol withdrawal. Seven patients received octreotide 200 to 400 microg per day, 5 of whom subsequently underwent surgery (71%). Fourteen patients out of 23 were operated on (61%), 11 of whom underwent pancreaticoduodenectomy and remained symptom-free for 47 months follow-up. Mean follow-up was 56 months (range: 2-78) for non surgical patients (39%) and 47 months (range: 12-108) for surgical patients (61%). CONCLUSION: Cystic dystrophy of the duodenal wall complicating chronic alcoholic pancreatitis may be the revealing sign of pancreatitis. Endoscopic ultrasongraphy is the most reliable imaging method for diagnosis. Pancreaticoduodenectomy is the most frequently employed definitive treatment.

[Endoscopic drainage of cystic dystrophy of the duodenal wall: report of three cases]. / Traitement endoscopique de la dystrophie kystique de la paroi duodénale. A propos de trois cas.

Optimal management of cystic dystrophy of a heterotopic duodenal pancreas or cystic dystrophy of the duodenal wall has not yet been established. Surgical treatment by pancreaticoduodenectomy or by-pass procedure is indicated in patients with the most serious symptoms. Endoscopic cystic drainage is an alternative to surgery. We report three cases of cystic dystrophy of the duodenal wall successfully treated by endoscopic drainage. Symptoms disappeared immediately in all cases. No complications were observed. In one case, a second drainage was necessary 15 months after the first one. The 3 patients were free of symptoms after 6, 36, and 44 months of follow-up, respectively. No recurrence was found with CT-scan. The long-term efficiency of the endoscopic procedure must to be evaluated.

[Acute tubular necrosis with acute renal failure during the first month of treatment with 5-amino-salicylate (Pentasa(R))]. / Insuffisance rénale aiguë par nécrose tubulaire aiguë au cours du premier mois de traitement par l'acide 5-amino-salicylique (Pentasa(R)).

We report a case of acute tubular necrosis in a patient with Crohn's disease treated by 5-amino-salicylate (Pentasa(R)) since one month. Normalization of renal biological parameters occurred rapidly after treatment withdrawal. This case raises the question of the optimal modalities of monitoring of renal function during treatment with 5-amino-salicylate.

[Pancreatic tuberculosis: a rare cause of pseudoneoplastic obstructive jaundice]. / Tuberculose pancréatique: une cause rare d'ictère pseudo-néoplasique par compression de la voie biliaire principale.

Isolated pancreatic tuberculosis is rare, and can mimic pancreatic carcinoma. We report a case of pseudoneoplastic pancreatic tuberculosis revealed by an obstructive jaundice in a 35-Year-old man. Surgical pancreatic histopathology showed a caseating granulomatous inflammation and diagnosis was confirmed by detection of Mycobacterium tuberculosis DNA using specific polymerase chain reaction-based assay (PCR). The patient was successfully treated with quadruple antituberculous therapy. In the context of the diagnostic work-up of a hypodense pancreatic mass, the diagnosis of tuberculosis relies on the presence of pancreatic caseating granulomas, that can be obtained by endosonography-guided biopsy, thus avoiding laparotomy.

[Alpha-fetoprotein-producing poorly differentiated gastric adenocarcinoma: hepatoid carcinoma?]. / Adénocarcinome gastrique peu différencié produisant de l'alfafoetoprotéine: tumeur hépatoïde?

We report the case of a 42-Year-old man with a poorly differentiated gastric cancer revealed by a very high level of serum alpha-fetoprotein-protein, associated with liver metastasis, and treated by chemotherapy. We discuss the possible diagnosis of hepatoid carcinoma.